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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. _ <br /> t FOR OFFICE USE: APPLICATION } - <br /> i (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> 4 ENVIRONMENTAL HEALTH PERMIT <br /> i (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> t Application is hereby made to the an Joaquin Local althDistrictforapermit-to construct and/or install the work herein described.This application is <br /> made in compliance wk0p din is q.. 1862 and the rules and_regulatjons of the San Joaquin Local Health District. <br /> Exact SiteAddressRiyer Meadows bdivision, abd rd e=Rd.;City/Town Woodbridge <br /> I Owner's Name George Ferreo!. Phone_334-0670 <br /> Address Pinel city—Lodi , CA <br /> Contractor's Name Clark Well & Equipment License# � I 6.Q Business Phone 462-5597 �J <br /> Contractor's Address 2024 E Charter Way Emergency Phone t' 1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHI7? Yes X No <br /> L TYPE OF WORK (CHECK): NEW WELLZ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ v <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ i <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL a; ' <br /> 0 INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 2411 ' <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 14" <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing . 188 <br /> I ❑ IRRIGATION 1E3-GRAVEL PACK Depth of Grout Seal 50f <br /> i ❑ CATHODIC PROTECTION ❑.RQTARY' Type of Grout Cement Sack Mix T <br /> ❑ DISPOSAL © OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H,P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure `V- <br /> I <br /> -I herebY certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. ' <br /> "Ish <br /> r ' ensed agent's signature certifies the following:1 certify that in the performance of the work for which this permit <br /> F I not employ any person in such manner as to become subjectto workman's compensation laws of California."I( ring or sub-c ractiTtgrouting <br /> a certifies the following:"l certify that in the performance of the work for which this <br /> d, I hall y perct to workman's compensation laws of California." 2G n pe i n rand a final inspection. <br /> Signed X Title: Sec—Tres , C lark Well Date: 11_ Jan .,8 2 <br /> I (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> Application Accepted By 1� Date <br /> Additional Comments:- <br /> Phase <br /> omments:Phase II Grout Inspection Phase III Final Ins tion <br /> e :' . Inspection By Date Inspection By ` ate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 3.1 <br /> s <br /> BILLING REMITTANCE $ REMIT <br /> ' BASE EXPLANATION PATE DATE REMITTED AMOUNT DUE CHECKED - - <br /> ! AMOUNT <br /> li7- FEE <br /> LESS fix. <br /> PRORATION <br /> PLUS 1 <br /> PENALTY <br /> OTHER _ <br /> - a <br /> OTHER' I # <br /> "--�eived by Date-- - Receipt No Permit No I Issuence Date Mailed Delivered - - <br /> - -'�--RfTURN.ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />